Another important consideration is that of illicit drug use, particularly crack cocaine use, which is a major social problem in the United States, particularly in large urban populations. A number of cases illustrating a temporal association between heavy crack use and severe acute exacerbation of asthma, including fatal asthma, have been reported.

The increase in cocaine use seems to parallel the increase in asthma morbidity and mortality, suggesting there may be an association between the two. Levenson et al reviewed cases of asthma deaths in the Chicago area. Their findings were that 29 of 92 cases (31.5%) were confounded by substance abuse (including cocaine) or alcohol use. Thus far, the prevalence of cocaine use among patients presenting with acute asthma is unknown, and crack cocaine may be unrecognized as a precipitant for asthma exacerbations.

This study addresses the prevalence of illicit drug use—particularly cocaine—among adults presenting to an inner-city emergency department (ED), and the relationship of cocaine use and severity of asthma exacerbation. A secondary aim was to assess the frequency of use of various treatment modalities for asthma, particularly inhaled corticosteroids (ICS) and P₂-agonists, with reference to the 1997 National Asthma Education and Prevention Program (NAEPP) guidelines.

Materials and Methods

We conducted a prospective study to determine the prevalence of cocaine use and its impact on severity in adult patients presenting to an inner-city ED with acute asthma exacerbation.

The Canadian Network for Mood and Anxiety Treatments describes anxiety as the body’s way of telling us that we feel vulnerable and unprepared. It is anxiety that makes sure we are vigilant and equipped to accomplish the tasks or situations facing us, like exams, an icy road or a challenging social or work situation. Without anxiety, our response to those types of stressful situations could be inadequate and lead to undesirable consequences.

We need a certain amount of anxiety to function effectively. It is when anxiety becomes prolonged and disrupts out daily lives that it becomes pathological.

Anxiety disorders are the most common mental health problems. Anxiety affects twice as many women as men and occurs in about ten per cent of the population, including children. Anxiety disorders are illnesses yet they are often perceived as mental weakness or character flaws.

The website of the Canadian Mental Health Association states that the disorders affect the behaviour, thoughts, emotions and physical health of the people who experience them. Research shows that they are caused by biological and circumstantial factors, just like other illnesses such as heart disease and diabetes. Individuals can experience more that one type of anxiety disorder and can be accompanied by depression, eating disorders and substance abuse.
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Anxiety disorders include Generalized Anxiety Disorder, or GAD, Obsessive Compulsive Disorder, Post Traumatic Stress Disorder, Panic Disorder and specific phobias. These diagnosable illnesses are treatable. Left untreated, the individual experiencing the illness can be distressed and cause distress to those around them. The disorders can be disruptive and severely limit normal activities.

The two main treatment approaches are cognitive behavioural therapy and drug therapy. Anti-depressant and anti-anxiety medications are generally prescribed because most anxiety disorders have some biological component. Cognitive behavioural techniques include helping people to turn their anxious thoughts into thoughts that are less anxious and more rational.

Because of the stigma associated with mental illness generally and anxiety disorders specifically, many anxiety disorders go untreated and continue to disrupt the lives of the individuals who experience them.

Off-Label Use of Atypicals May Do More Harm Than Good

Off-label use of atypical antipsychotics may do more harm than good, a new meta-analysis suggests.

A combined analysis of more than 150 efficacy trials showed significant increases in behavioral symptom scores for dementia in the elderly after they were treated with aripiprazole, olanzapine, or risperidone; benefits for nonelderly patients with generalized anxiety disorder (GAD) after they received quetiapine; and benefits for patients with obsessive-compulsive disorder (OCD) after receiving risperidone augmentation.

However, analysis of more than 200 adverse outcome studies showed that treatment-related adverse events, including death, were common in these patient groups.

“Besides the small but statistically significant effect found for dementia, the other improvements were a bit smaller than we expected, with moderate effects for GAD and OCD,” lead author Alicia Ruelaz Maher, MD, psychiatrist at the Akasha Center for Integrative Medicine in Santa Monica, California, and assistant clinical professor in psychiatry at the University of California, Los Angeles, School of Medicine, told Medscape Medical News.

“As for the other conditions that these medications commonly treat, we just did not find enough of an effect. And despite olanzapine being known to cause weight gain, I was surprised to find it was not effective in causing weight gain in eating disorders,” said Dr. Maher, who is also a clinical adjunct at the RAND Health Southern California Evidence-Based Practice Center in Santa Monica.

She noted that the study is the “largest study of its kind on this subject,” and prompted clinicians to reconsider the way they prescribe atypical antipsychotics.

“I think the biggest takeaway is that instead of just prescribing blindly, we now have evidence to guide us. There are certainly times when the cost-benefit analysis would go towards using medication, but I would hope that the side effects are kept in mind.”

The study appears in the September 28 issue of JAMA.

Doubling of Off-Label Use

“Atypical antipsychotic medications are approved for marketing and labeling by the US Food and Drug Administration (FDA) for treating schizophrenia, bipolar disorder, and depression under drug-specific circumstances,” write the researchers.

However, these medications “are commonly used” off-label to treat dementia, anxiety, OCD, eating disorders, substance abuse, and posttraumatic stress disorder.

“We’ve been noticing that off-label use is increasing. In fact, over the past several years it has doubled,” said Dr. Maher.

“Some clinicians feel that if a medication is effective in treating 1 condition, it might also be effective in treating others. And that often works, especially in psychiatry. However, there are also plenty of instances where off-label use was determined to be useless or even harmful.”

To evaluate the benefits and safety of these medications for off-label use, the investigators examined data from 162 trials with efficacy outcomes conducted through May 2011.

“Controlled trials comparing an atypical antipsychotic medication (risperidone, olanzapine, quetiapine, aripiprazole, ziprasidone, asenapine, iloperidone, or paliperidone) with placebo, another atypical antipsychotic medication, or other pharmacotherapy for adult off-label conditions were included,” report the researchers.

“Clozapine was excluded due its almost exclusive use for schizophrenia,” they add.

Minimal Efficacy

A total of 231 large observational studies were also examined that assessed adverse events and included at least 1000 patients each.

The efficacy review included 14 placebo-controlled trials that evaluated elderly patients with dementia who had symptoms such as psychosis, mood alterations, and aggression.

Overall results showed that aripiprazole, olanzapine, and risperidone showed small but significant effect changes, ranging from 0.12 to 0.20. Quetiapine showed an effect change of 0.11, but this was not deemed significant.

There was a difference of 3.41 points in the pooled Neuropsychiatric Inventory total score for dementia behavior symptoms between treatment with antipsychotics and with placebo. However, this was below the 4-point improvement threshold “considered to be the minimum clinically observable change,” report the researchers.

In combined analysis of trials evaluating GAD, a “favorable response” was defined as showing at least 50% improvement on the Hamilton Anxiety Rating Scale. Overall results showed that quetiapine was associated with a 26% greater likelihood of a favorable response at 8 weeks than placebo.

Augmentation with risperidone after not responding to other treatments was associated with a 3.9-fold greater likelihood than placebo of a favorable response (showing at least a 25% improvement on the Yale-Brown Obsessive Compulsive Scale) for patients with OCD.

The study authors note that “evidence does not support” using olanzapine to treat eating disorders, or using any antipsychotic medications to treat substance abuse. Furthermore, they add, “[t]he level of evidence is mixed regarding personality disorders and is moderate for an association of risperidone with improving [posttraumatic stress disorder].”

Rethinking Off-Label Use

Adverse events in elderly patients included an increased risk for death (pooled odds ratio, 1.54) and urinary tract symptoms overall, stroke for risperidone, and extrapyramidal symptoms for olanzapine and risperidone compared with placebo.

In the nonelderly, treatment-related adverse effects from antipsychotics included weight gain (especially with olanzapine), extrapyramidal symptoms, fatigue, sedation, and akathisia for aripiprazole.

“This systematic review demonstrates evidence for the efficacy of atypical antipsychotic medications for only a few of the off-label conditions that are currently being treated,” write the researchers.

“This evidence should prove useful for clinicians considering off-label prescribing…and should contribute to optimal treatment decision-making for individual patients with specific clinical symptoms and unique risk profiles.”

Dr. Maher added that she hopes this leads to clinicians examining each patient’s individual needs.

“For example, if a patient already has kidney problems, then urinary tract symptoms might be a bigger issue than in someone who doesn’t. It’s just really about looking at the individual.”

However, she also noted that although moderate levels of evidence were found for some of these conditions, further research might bring about changes in the results.

“We need to use this information and be wary of prescribing when it isn’t warranted; but also we need to keep looking at this issue in future studies.”

A Complicated Decision

“While meta-analysis studies are always useful, one doesn’t make treatment decisions based on just 1 [study],” Anthony Rothschild, MD, Irving and Betty Brudnick endowed chair and professor of psychiatry at the University of Massachusetts Medical School in Worcester, and director of the Center for Psychopharmacologic Research and Treatment, told Medscape Medical News.

Caveats of chronic exogenous corticosterone treatments in adolescent rats and effects on anxiety-like and depressive behaviour and HPA function

Administration of exogenous corticosterone is an effective preclinical model of depression, but its use has involved primarily adult rodents. Using two different procedures of administration drawn from the literature, we explored the possibility of exogenous corticosterone models in adolescence, a time of heightened risk for mood disorders in humans.

Methods: In experiment 1, rats were injected with 40 mg/kg corticosterone or vehicle from postnatal days 30 to 45 and compared with no injection controls on behavior in the elevated plus maze (EPM) and the forced swim test (FST).

Experiment 2 consisted of three treatments administered to rats from postnatal days 30 to 45 or as adults (days 70 to 85): either corticosterone (400 μg/ml) administered in the drinking water along with 2.5% ethanol, 2.5% ethanol or water only. In addition to testing on EPM, blood samples after the FST were obtained to measure plasma corticosterone.

Analysis of variance (ANOVA) and alpha level of P <0.05 were used to determine statistical significance.

Results: In experiment 1, corticosterone treatment of adolescent rats increased anxiety in the EPM and decreased immobility in the FST compared to no injection control rats. However, vehicle injected rats were similar to corticosterone injected rats, suggesting that adolescent rats may be highly vulnerable to stress of injection.

In experiment 2, the intake of treated water, and thus doses delivered, differed for adolescents and adults, but there were no effects of treatment on behavior in the EPM or FST. Rats that had ingested corticosterone had reduced corticosterone release after the FST.

Ethanol vehicle also affected corticosterone release compared to those ingesting water only, but differently for adolescents than for adults.

Conclusions: The results indicate that several challenges must be overcome before the exogenous corticosterone model can be used effectively in adolescents.

Is individual therapy overrated and outdated? Yes, says Alan Kazdin, a professor of psychology and child psychiatry at Yale University, writing in the leading journal Perspectives on Psychological Science.

Kazdin contends that treatments for mental health issues have made great strides over the last few decades, but the problem is that these evidence-based therapies aren’t getting to the people who need them. Nearly 50% of the American population will suffer some kind of mental illness at least once in their lifetimes, but the mental health field, which relies largely on individual psychotherapy to deliver care, isn’t equipped to help the vast majority of patients.

TIME spoke with Kazdin about his views and recommendations for change.

Q: Why did you decide to speak out about this issue?

A: For me, it’s like an emperor’s new clothes situation. All these people — including me — do very expensive controlled trials of therapy and yet we see that most people aren’t getting treatment at all. Something is wildly, drastically wrong.

In Manhattan, which has no shortage of therapists, I’ve asked for referrals for evidence-based treatments like cognitive behavioral therapy and several times had high-level professionals be unable to provide one.

Totally! [It is hard to get] evidence-based treatments. Among the many reasons is that scientific innovation in any field normally takes a decade or two to filter down to the public. It’s somewhat sad, but normal. Most people practicing who are 50 years old or older weren’t trained in them and they don’t know how.

Many therapists say they want to be “eclectic,” rather than trying any new treatment system that has been proven to work.

That’s a red herring: I individually tailor treatment specifically for you. The research shows that no one knows how to do that. [And they don’t know how to monitor your progress.] Think about if you went to your physician and had a blood test, but they never read the results. They don’t have any idea if you’re getting better. It’s ridiculous.

So why aren’t patients clamoring for better therapy?

This is a very sad commentary for me. When I was starting out, I thought that the public would be an ally, but research shows that satisfaction with therapy is not very much related to getting better. [So, they don’t necessarily realize they are not getting good treatment.]

What do you think should be done?

The first thing we need is the commitment of professionals to really help people. We need very different ways of giving treatment. Many of them are out there already. For example, there are online treatments. There’s self-help that could reach millions of people in need, if we did things other than one-to-one New Yorker cartoon psychotherapy. We should have more guidelines [about what to do therapeutically] — that would offend the profession, but benefit the public.

I’m proselytizing only because someone has to look at this inertia. Right now in time zones all over country, someone is getting evidence-based treatment but there are eight or nine other people who aren’t getting anything.

But if you don’t have professional guidance, there’s lots of self-help that is ineffective or even harmful.

Here’s what’s really hard. The self-help literature has a pile of evidence-based treatments that are well-studied in randomized controlled trials. But the poor public has no chance. You go to the bookstore or look online, and 99% of what you get is someone winging it. Those are not usually evidence based.

The profession should be out there taking the moral high ground [and providing appropriate guidance].

There are a couple of online cognitive behavioral treatments for clinical depression that have been shown to work in randomized controlled trials. The profession should be proselytizing, telling people that there’s online treatment that’s free or inexpensive, and if that doesn’t help, then maybe you should see a therapist.

But what about the studies suggesting that it’s the relationship between the therapist and the client — not the technique — that matters?

There’s no real evidence for this. Yes, a good relationship is related to clinical outcome but it plays no causal role whatsoever. Some new therapies don’t require a relationship at all. For example, there’s essay-writing therapy for trauma. It’s a set of self-administered treatments, there’s no relationship there — it’s not even an essential condition.

It’s way overplayed. We did a study showing that the relationship isn’t so special. The quality of the relationship [between therapist and patient] relates to how social the patient was before treatment. It may be correlated to effectiveness of treatment, but the relationship has not shown to be causally involved.

If you want to get over an anxiety disorder, do graduated exposure. But sit down and relate to me or love me like your mom and dad? There’s no evidence for that.

Exposure Therapy for Anxiety Disorders

Over a quarter of the people in the US population will have an anxiety disorder sometime during their lifetime. It is well established that exposure-based behavior therapies are effective treatments for these disorders; unfortunately, only a small percentage of patients are treated with exposure therapy. For example, in the Harvard/Brown Anxiety Research Project, only 23% of treated patients reported receiving even occasional imaginal exposure and only 19% had received even occasional in vivo exposure. In part, this may be a lack of well-trained professionals, because most mental health clinicians do not receive specialized training in exposure-based therapies.

Another factor may be that many health care professionals do not understand the principles of exposure or may even hold (usually unfounded) negative beliefs about this form of treatment. Surveys of psychologists who treat patients with PTSD show that the majority do not use exposure therapy and most believe that exposure therapy is likely to exacerbate symptoms. However, individuals with trauma histories and PTSD express a preference for exposure therapy over other treatments. Furthermore, exposure therapy does not appear to lead to symptom exacerbation or treatment discontinuation.10 Indeed, a wealth of evidence indicates that exposure-based therapy is associated with improved symptomatic and functional outcomes for patients with PTSD.11

The available research literature suggests that exposure-based therapy should be considered the first-line treatment for a variety of anxiety disorders. Here we review a handful of the most influential studies that demonstrate the efficacy of exposure therapy. We also discuss theoretical mechanisms, practical applications, and empirical support for this treatment and provide practical guidelines for clinicians who wish to use exposure therapy and empirical evidence to guide their decision making.

Exposure therapy is defined as any treatment that encourages the systematic confrontation of feared stimuli, which can be external (eg, feared objects, activities, situations) or internal (eg, feared thoughts, physical sensations). The aim of exposure therapy is to reduce the person’s fearful reaction to the stimulus.

Open house to discuss anxiety disorders

The Psychiatry Department will hold an open house at 5pm on Thursday to discuss signs and symptoms of anxiety disorder.
The lecture and open discussion will be led by Hamad Medical Corporation’s psychology supervisor, Mariana Barrancos, whose areas of expertise include adjustment disorders, anxiety and depression, trauma and cultural diversity.
Anxiety is one of the most common psychological disturbances and its frequent symptoms may include excessive worries and fear, nervousness, irritability, shortness of breath, insomnia, a racing heartbeat, nausea, dizziness and shaking.
Other symptoms may manifest as gastrointestinal problems, insomnia and headaches which increase the patient’s level of discomfort.
In addition, anxiety disorders may coexist with other psychological disturbances, such as depression and an increased risk for substance abuse.
The lecturer will also discuss how to understand the multiple risk factors of anxiety symptoms as will describe different types of anxiety disorders, treatment options and healthy strategies to help people manage it.
Barrancos’s institutional work focused on the prevention and treatment of multiple forms of abuse, trauma and emotional deprivation in children, adolescents and adults.
The lecture is part of a series of open days held on the second Thursday of every month throughout 2011, which aim to educate the public on various aspects of mental illness and mental health.
However, the Psychiatry Department, which is planning a slew of activities to mark this year’s World Mental Health Day on October 10, will also hold a symposium on new advances in mental health mid-December.

Most children with asthma develop symptoms before the age of six, and many begin wheezing before one year. It is important to diagnose infant asthma because if left untreated, inflammation can cause permanent damage to the lungs, says Dr. Samya Helmi, a pediatrician at a private clinic.

Asthma affects an estimated 300 million individuals worldwide. The prevalence of asthma is increasing, especially in children. Annually, the World Health Organization (WHO) has estimated that 15 million disability-adjusted life-years are lost and 250,000 asthma deaths are reported worldwide. Approximately 500,000 annual hospitalizations (34.6 percent in individuals aged 18 years or younger) are due to asthma. In the United States, asthma prevalence, which has increased from 1980 to 1996, showed a plateau at 9.1 percent of children (6.7 million) in 2007.

Helmi defines asthma as a chronic disease of the lungs that causes the airways to swell, tighten and generate a huge amount of mucus. According to her, children are more likely to develop asthma if there’s a family history of allergies and asthma. “Researchers are sure of this fact, especially if a child’s parents have asthma and certain allergies,” she said.

Helmi said that if a baby has a cold and is wheezing, the mother might wonder if the problem is asthma, although it’s not always clear. More important than getting a firm diagnosis is making sure the child gets treated for any breathing problems. “Asthma can be difficult to diagnose in children under the age of five, especially in infants, because other conditions have related symptoms,” she said.

Pregnant mothers who use hairdryers, hair dye, microwaves, vacuum cleaners or who are near any kind of smoke could be putting their babies at risk of asthma, claims Helmi. “Pregnant women should stay away from any kind of threat that can harm the child like X-rays, smoke produced by cigarettes or cooking, hairdryers, microwave fans, coffee grinders and chemical cleaning products,” she says. “Researchers have already shown that this type of magnetic energy and chemicals can increase the risk of miscarriage and some types of cancer.”

Just as in adults, infant asthma symptoms can vary from child to child. In infant asthma, babies may have all the classic adult asthma symptoms from wheezing, chest tightness, and cough to shortness of breath. Additionally, poor feeding, sweating or appearing uncomfortable may be symptoms of infant asthma, says Helmi.

She says one of the most important abilities as a parent of a child with asthma-like symptoms is to know when it is needed to call a doctor or head to the emergency department. “If a mother suspects wheezing and the child has never wheezed before, it is important to promptly see a health care provider to figure out what is causing the wheezing,” she added.

Helmi states that asthma symptoms can be recognized from the following:
Unexplained diarrhea or constipation
Extreme likes and dislikes for certain foods
Extreme nighttime cough
Wheezing after exposure to allergens
Wheezing after crying or laughing
Child breathes so fast that they have difficulty finishing a bottle
Persistent loss of weight
Excessive vomiting
Sudden pain in the chest or heaviness in the chest

When asked if a mother can stop her baby from getting asthma, Helmi said that asthma seems to be connected between the child’s genes and the child’s environment, both before and after birth, and especially in the first year.

“I highly recommend mothers to breast-feed their babies for it may reduce the risk of asthma in early childhood. However, as yet, there is no evidence that breast-feeding protects against asthma for longer than this,” she said. “In addition, mothers should avoid potential allergens in their daily diet such as cheese, nuts, shellfish and eggs during pregnancy and breast-feeding. They should also keep their babies away from smoke, pets, dust and chemicals.”

Infant asthma is treated with many of the same medications as adult asthma. “A doctor can explain how to give the medication to the baby, and he/she might prescribe a reliever inhaler with or without medicine. For babies and young children, the doctor might prescribe an reliever inhaler that is attached to a small spacer chamber, which is attached to a face mask. The inhaler is pressed by the parent or doctor to dispense the medicine into the holding chamber, and the baby’s own breathing then draws in the medicine from the spacer via the face mask,” she explained.

If the baby has been treated with asthma medication and got better on this treatment, then the doctor may ask the mother to continue with this method. The mother will need to have the child checked regularly by the doctor, as changes in treatment are likely as the baby grows.

“If the baby continues to cough or wheeze despite a trial of asthma medicine, this may mean that the baby needs to be reassessed as another condition may be causing his/her symptoms,” said Helmi.

Better asthma treatment for mums-to-be

Australian researchers have devised an improved way of managing asthma which they say could lead to a 50 per cent reduction in attacks in pregnant women.

One in 10 women in Australia have asthma and pregnant women are particularly prone to attacks, says Peter Gibson, a staff specialist at John Hunter Hospital and professor at Newcastle University.

“It’s not only a problem for the mother, it’s also a problem for the baby,” Professor Gibson told AAP on Friday.

“Asthma in pregnancy is associated with low birth weight babies, pre-term labour and an increased rate of the baby having to be hospitalised after birth.”

Currently, asthma medication is delivered according to clinical symptoms, which can result in the condition being under- or over-treated.

But Prof Gibson has developed a system that allows doctors to match the amount and frequency of steroid-based treatments to airway inflammation.

His research, involving asthmatic pregnant Australian women and published in the Lancet on Friday, found that adjusting treatment to match levels of inflammation led to a 50 per cent reduction in asthma attacks.

The research was based on 220 pregnant non-smoking women with asthma in John Hunter and Maitland hospital antenatal clinics.

Prof Gibson and his team measured airway inflammation and adjusted the treatment using a particular chemical marker.

“It’s a much more precise way of adjusting treatment for someone with asthma,” he said.

The results were “fantastic”, he said.

“We want the obstetricians and midwives to get excited about this and think about how they can implement it in their clinics. We want to help them do that,” Prof Gibson said.

The same technique could also work for non-pregnant people with asthma, Prof Gibson said, adding he planned further study in that area.

“There’s no reason why you couldn’t use the same algorithm in anyone with asthma (although) we obviously need to prove that before we go out there saying that’s what we should do,” he said.

Tools to manage Asthma exist

The Global Asthma Report 2011 shows the tools to manage asthma exist but are not reaching many of the 235 million people affected. Asthma is the most common chronic disease among children and also affects adults. “The tools to treat asthma are already available – there is no reason to delay”, says Dr Nils E Billo, Executive Director of The International Union Against Tuberculosis and Lung Disease (The Union). “Moreover, when asthma is not diagnosed, not treated or poorly managed, and when people can not access or afford treatment, they regularly end up having to miss school or work, they are unable to contribute fully to their families, communities and societies, they may require expensive emergency care, and everyone loses. The obstacles to well-managed asthma can be overcome. Asthma is a public health problem that can – and should be addressed now” added Dr Billo.

Worldwide, 235 million people have asthma. For these people, asthma can mean struggling for breath when they have an asthma attack, a diminished quality of life, disability and even death. Although effective treatment is available, many people with asthma, especially in low- and middle-income countries, are unable to access or afford it.

To highlight the issues surrounding this major non-communicable disease, the International Union Against Tuberculosis and Lung Disease (The Union) and the International Study of Asthma and Allergies in Childhood (ISAAC) have collaborated to produce the Global Asthma Report 2011, which will be launched at an event sponsored by the Non-Communicable Disease Alliance on Saturday, 17 September 2011, at the New York Academy of Medicine. Release of the report coincides with the UN High-Level Meeting on NCDs taking place on 19–20 September.

Designed for stakeholders from government ministers and policy-makers to health workers and people with asthma, the Global Asthma Report 2011 is a richly illustrated “atlas” that provides an overview of what is known about the causes and triggers of the disease, the global prevalence, the progress being made and the significant challenges today and for the future.

Key findings in the Global Asthma Report 2011:

- ISAAC data show that asthma in children is increasing in low- and middle-income countries, where it is more severe than in high-income countries.

- The World Health Survey found an 8.2% prevalence of diagnosed asthma among adults in low-income countries and 9.4% in the richest countries. Middle-income countries had the lowest prevalence at 5.2%.

- Smoking and secondhand smoke are two of the strongest risk factors – and triggers – for asthma.

- Although asthma is frequently thought of as an allergic disease, this does not apply to all cases, and the non-allergic mechanisms need to be the focus of more research.

- Surveys around the world found asthma treatment falling short, with few patients consistently using the inhaled corticosteroids that effectively manage the disease. For example, the Asthma in America survey found only 26.2% of patients with persistent asthma used these medicines.

- While many countries now have asthma management guidelines, many health workers do not know how to diagnose or treat asthma and health systems are not organised to handle this type of long-term, chronic disease.

- A 2011 Union survey of the pricing, affordability and availability of essential asthma medicines in 50 countries found dramatic variations. For example, one generic Beclometasone 100μg inhaler in a private pharmacy cost the equivalent of nearly 14 days’ wages – and a patient with severe asthma

requires about 16 of these inhalers per year.

- The Asthma Drug Facility established by The Union has been able to bring down the cost of treating a patient with severe asthma to approximately US$ 40 per year.

- When people do not have access to ongoing care, they often end up in emergency rooms and hospitals — a costly and unnecessarily disruptive process for all involved.

- Although economic data are unavailable for almost all low-income countries, a 2009 systematic review found annual national costs (in 2008 US dollars) ranging from $8,256 million in the United States to $4,430 million in Germany.

- Success stories from five high- and low-income countries that have implemented asthma management activities show that well-managed asthma saves money – and enables people to get on with their active lives. For example, in Finland, the mortality, number of hospital days and disability due to asthma fell 70–90% between 1994 and 2010 and a conservative estimate of the savings was $300 million in 2007 alone.

Australian-New Zealand biotech Living Cell Technologies has expanded its clinical trials to a third region, kicking off a study of its DIABECELL treatment for Type 1 diabetes in Buenos Aires, Argentina.

The xenotransplantation treatment uses insulin-producing cells from pigs that are specially encapsulated and surgically implanted into the patient, allowing them to produce insulin.

Two patients with Type 1 diabetes have already been signed up, with up to six more to be added to the trial, including individuals with unstable diabetes and severe hypoglycaemia.

The patients in the trial will each receive two implants of DIABECELL three months apart, which is a different approach to that used in previous trials.

“We have a treatment that works,” said LCT medical director and acting CEO Bob Elliott. “However, during this next stage of our clinical trial we will use fewer insulin producing cells, implanted on two occasions and also utilise a different implantation technique to determine if we can provide patients with even greater benefit. The cells were produced by an improved technique that can also be more readily upscaled,” he said.

“We hope to see the effect of these even lower and repeated doses. We are looking for most effective combination before we enter into our final stages of commercialisation.”

LCT will also employ a new variation of the company’s patented IMMUPEL cell encapsulation technique. The new process avoids a source of capsule imperfection that may affect function. IMMUPEL is used to encapsulate the porcine insulin producing cells to prevent rejection by the recipient.

LCT stock (ASX:LCT) rose 5% today to 6c in afternoon trading.

DMP for diabetes type 1: guidelines indicate some need for revision

On 22 August 2011, the German Institute for Quality and Efficiency in Health Care (IQWiG) published the results of a literature search for evidence-based clinical practice guidelines on the treatment of people with diabetes mellitus type 1. The aim of the report is to identify those recommendations from current guidelines of high methodological quality that may be relevant for the planned revision of the corresponding disease management programme (DMP). According to the results of the report, there is no compelling need for revision of any part of the DMP. However, IQWiG identified various aspects that could be supplemented and specified.

Evidence was documented in detail

One of the responsibilities of IQWiG specified by law (Social Code Book V) is to develop and issue recommendations for DMPs. In the commission now completed, which was awarded by the Federal Joint Committee (G-BA), IQWiG systematically searched for new guidelines, assessed their methodological quality, and extracted relevant recommendations on the diagnosis and treatment of diabetes mellitus type 1, its accompanying diseases and late complications, as well as on the cooperation of health care sectors. In addition, the Institute documented how highly the guideline authors graded the robustness of the recommendations. However, the sources of the recommendations were not examined again; this is where IQWiG’s guideline appraisals and benefit assessments differ.

No contradictions between the DMP and current recommendations

A total of 23 German and international guidelines containing recommendations on the treatment of diabetes type 1 were included. As the analysis showed, the recommendations in the guidelines are, by and large, consistent with the specifications of the DMP. No contradictions in content concerning the DMP requirements were found. The Director of IQWiG, Professor Dr med. Jürgen Windeler, stresses that “patients with diabetes mellitus type 1 can thus be sure that the current DMP is consistent with the current status of medical knowledge on all main points.”

Some potential additional recommendations identified for the DMP

However, in these guidelines recommendations were found on a total of 8 subject areas from which, after examination and discussion, the need may arise to update and supplement the German DMP for diabetes mellitus type 1.

For example, some guidelines recommend higher blood glucose levels (increase in HbA1C) in patients susceptible to hypoglycaemia, as well as dietary advice and therapy. Neither item has so far been included in the legal regulations on the DMP for diabetes mellitus type 1. Moreover, while the DMP currently mentions only the diagnosis and treatment of diabetic retinopathy, guidelines also include recommendations on the treatment of clinically relevant macula oedema. These three aspects of treatment could in future be additionally considered in the DMP.

It is the Institute’s responsibility, first of all to identify differences between guideline recommendations and the DMP. The Federal Joint Committee then examines whether these differences should actually lead to a revision of the DMP for diabetes mellitus type 1.

Procedure of report production

IQWiG published the preliminary results in the form of the preliminary report in November 2010 and interested parties were invited to submit comments. When the comments stage ended, the preliminary report was revised and sent as a final report to the contracting agency, the Federal Joint Committee, in June 2011. The written comments are published in a separate document at the same time as the final report. The report was produced in collaboration with external experts.

Warning about effects of cabin pressure on diabetes

Scientists in Australia have issued a warning about the effects of cabin pressure on insulin dispensers. A study has shown that in-flight cabin pressure could result in insulin pumps delivering either too much or too little of medication, which could put more sensitive diabetics at risk.

The research recommended that people disconnect their pump before flying, and ensure there are no air bubbles in the insulin when they reconnect it at cruising altitude and again on landing.

The study examined ten different insulin pumps, mainly used by people suffering from type 1 diabetes to deliver insulin throughout the day, finding that during takeoff, as the air pressure decreased, the pumps were delivering around small amounts of extra insulin, while during landing, when the pressure is increasing, some insulin was going back into the pumps so that they delivered too little of the treatment.

The study, which was published in the journal Diabetes Care, said that the problems were not common but could mean diabetics receiving the wrong amounts of insulin. The suggested a range of safety checks, including insulin cartridges only containing a certain amount of insulin.

Researcher Bruce King said “I believe most people would rather know exactly how much insulin their pumps were giving. Following the recommendations means that they know and are in control of what is happening with their pump.”

Professor Robert Thomas: “You can reduce the chances of cancer coming back if you continue to exercise”
All patients getting cancer treatment should be told to do two and a half hours of physical exercise every week, says a report by Macmillan Cancer Support.

Being advised to rest and take it easy after treatment is an outdated view, the charity says.

Research shows that exercise can reduce the risk of dying from cancer and minimise the side effects of treatment.

The Department of Health says local initiatives can get people moving.

Macmillan’s report, Move More, says that of the two million cancer survivors in the UK, around 1.6 million are not physically active enough.

Adult cancer patients and cancer survivors should undertake 150 minutes of moderate intensity physical activity per week, the reports says, which is what the Department of Health guidelines recommend.

In the report, the American College of Sports Medicine also recommends that exercise is safe during and after most types of cancer treatment and says survivors should avoid inactivity.
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It doesn’t need to be anything too strenuous, doing the gardening, going for a brisk walk or a swim, all count”
Ciaran Devane
Macmillan Cancer Support

Getting active, the report says, can help people overcome the effects of cancer and its treatments, such as fatigue and weight gain.

“The evidence review shows that physical exercise does not increase fatigue during treatment, and can in fact boost energy after treatment.”

“It can also lower their chances of getting heart disease and osteoporosis.

“Also, doing recommended levels of physical activity may reduce the chance of dying from the disease. It may also help reduce the risk of the cancer coming back.”

Previous research shows that exercising to the recommended levels can reduce the risk of breast cancer recurring by 40%. For prostate cancer the risk of dying from the disease is reduced by up to 30%.

Bowel cancer patients’ risk of dying from the disease can be cut by around 50% by doing around six hours of moderate physical activity a week.

Ciaran Devane, chief executive of Macmillan Cancer Support, said physical activity was very important to the survival and recovery process.

“Cancer patients would be shocked if they knew just how much of a benefit physical activity could have on their recovery and long term health, in some cases reducing their chances of having to go through the gruelling ordeal of treatment all over again.

“It doesn’t need to be anything too strenuous, doing the gardening, going for a brisk walk or a swim, all count.”

Traditionally cancer patients were told to rest after their cancer treatment, but the report says this approach could put cancer patients at risk.

Jane Maher, chief medical officer of Macmillan Cancer Support and a leading clinical oncologist said: “The advice that I would have previously given to one of my patients would have been to ‘take it easy’.

“This has now changed significantly because of the recognition that if physical exercise were a drug, it would be hitting the headlines.”

Martin Ledwick, head information nurse at Cancer Research UK, was a little more cautious.

“Anything that improves wellbeing and reduces treatment side effects for cancer survivors has to be a good thing.

“But the evidence that exercise has a bearing on survival is not conclusive. It is important to remember that no two cancer patients are the same, so rehabilitation programmes that include physical activity will need to be tailored to the individual.”

A spokesperson from the Department of Health said it was vital that people with cancer are given the support to lead an active life.

“Physical activity and a healthy lifestyle can impact very positively on cancer outcomes and, as part of the National Cancer Survivorship Initiative, we are working with Macmillan to integrate physical activity services into cancer care pilot sites.

“Locally led initiatives such as Let’s Get Moving are also well placed to signpost cancer patients to community-based physical activity opportunities.”

Breast Cancer Patient Denied Treatment Because He’s a Man

When 26-year-old Raymond Johnson checked himself into the emergency room last month for a throbbing pain in his chest, the diagnosis shocked him. He had breast cancer. What came after that was an equally traumatizing blow. He was denied the Medicaid program that covers breast cancer treatment — because he’s a man.

In order to qualify for the breast cancer program (the Breast and Cervical Cancer Prevention and Treatment Act of 2000), one must meet a litany of eligibility requirements — all of which Johnson met, save for one. See, in order to receive the coverage, one’s cancer must be diagnosed by an “early detection” program funded by the Centers for Disease Control and Prevention. In South Carolina, where Raymond lives, this screening program is only offered to women between the ages of 47 and 64. In other words, since men don’t qualify for the early screening program, they’re not covered by the cancer treatment act.

Does anyone else see a problem with this system?

Actually, yes. The state Medicaid agency agrees. The department called the federal policy “discriminatory” and for at least the second time in two years is calling on the Centers for Medicare & Medicaid Services to change it. They said in a statement:

We are again urging CMS to reconsider. It’s a very clear example of how overly rigid federal regulations don’t serve the interests of the people we’re supposed to be helping.

I lost someone very near and dear to me to this awful disease, so my heart aches a little harder when I hear about someone diagnosed with it. But when I hear of people who can’t get proper treatment or coverage, my blood boils. My mother’s battle with cancer wasn’t a long one — and it certainly wasn’t a pretty one — but there was never a time when coverage or money was an issue for her and our family. She had good insurance, so we were always comfortable with the care she was receiving. That should be the case for everyone in this country.

In addition to the emotional and physical pain Raymond is going to experience while battling this disease (not to mention, most likely, a small sense of embarrassment for being diagnosed with a “female disease”), he’s going to have to deal with financial troubles as well. It’s going to be an non-stop uphill red tape battle for him all because he was born a man.

I am fully aware that breast cancer is predominantly a “woman’s disease,” but the fact is, 2,140 men are diagnosed with it each year. They should be covered as well, because, as Raymond himself eloquently put it, “Cancer doesn’t discriminate, so this program shouldn’t discriminate.”

Drugs’ scarcity strains care: Cancer patients may be affected

Shortages of drugs used to treat everything from leukemia to black widow spider bites are putting patients at risk — nationally and more recently in El Paso. And there appears to be no long-term solution in sight.

“We are facing an unprecedented shortage of critical medications used to treat a wide range of illnesses — from cancer to cystic fibrosis to cardiac arrest — that is causing significant risks to patient safety,” said U.S. Sen. Amy Klobuchar, D-Minn., who has proposed legislation intended as a first step in dealing with the issue. “Given the scope of the problem, it’s clear we need a coordinated strategy to root out the causes of these drug shortages and prevent them before they happen.”

Although drug shortages have been a problem since the 1990s, the scarcity of cancer treatment drugs has worsened in the last year, said Dr. Zeina Nahleh, chief of the Division of Hematology-Oncology in the Texas Tech Paul L. Foster School of Medicine’s Department of Internal Medicine. The only good news is that, so far, neither Nahleh nor Robert Reilly, University Medical Center associate pharmacy director, are aware of harm to patients in the El Paso area.

“We have been somewhat sheltered compared to the rest of the country,” said Reilly, a doctor of pharmacy. Larger cancer treatment centers were the first to feel the pinch, he said.

During the last six years, according to the U.S. Food and Drug Administration, the number of drug shortages nationally nearly tripled, jumping from 61 in 2005 to 178 in 2010. That includes cancer treatment drugs, anesthetics, antimicrobials and pain medications, but not products such as vaccines that are made from biological materials. A list maintained by the American Society of Health-System Pharmacists — which includes the biological drugs — earlier this week identified 193 shortages.

“We are on high alert now because we always have to look at the inventory and the drug list. It’s been really nerve-racking,” Nahleh said. “We’re trying to shield the patients, (but) we came very close to delaying treatment on a patient with leukemia. Somehow, we have been able to obtain the drug on time. … You cannot delay treatment for serious diseases like leukemia.”

Doctors are forced to make decisions about which patients are in the greatest need of the drugs available. And even when an alternative drug is identified, it can interact with other drugs, create more severe side effects and be less effective.

With first choices, “the cure rate is significantly improved,” Reilly said.

Many reasons for the shortages are cited, including manufacturing problems, distribution disruptions, difficulties obtaining raw materials, regulation issues and even natural disasters. But those tend to be temporary. Longer-lasting shortages often are related to drug manufacturers’ business decisions to discontinue or cut back production.

“One can’t help notice that generic (cancer treatment) drugs with their lower profit margins are particularly affected by the shortage,” Nahleh said.

When asked for comment, the Pharmaceutical Research and Manufacturers of America emailed a statement released last month. The organization represents many of the largest pharmaceutical drug companies, but not generic drug manufacturers.

“Our companies are deeply concerned with patients’ well-being and their ability to get needed prescription medications,” the statement says. “Drug shortages of any kind are a complex problem that require broad-based solutions from all stakeholders — including innovative biopharmaceutical research companies and generic manufacturers, whose products accounted for 78 percent of prescriptions filled last year.

“(I)n order to provide patients with uninterrupted access to medicines, it is important for all of us who provide life-saving medications to work collaboratively to minimize unexpected disruptions in the supply.”

An American Hospital Association survey of 820 hospitals nationwide, including some in Texas, revealed that nearly all had reported at least one shortage in the last six months and nearly half had 21 or more shortages. During that time, 82 percent had delayed treatment and more than half were not consistently able to provide recommended treatments, according to the study, which was released in July. Sixty-nine percent reported being forced to give patients a less-effective drug.

Nearly half reported experiencing shortages daily. And 35 percent reported that patients were experiencing “adverse outcomes.”

“Overall, the whole situation is stressful,” Reilly said. “We spend 20 or 30 hours a week trying to manage this situation.”

According to the hospital association, “labor costs associated with managing shortages translates to an estimated annual impact of $216 million nationally.”

And alternative drugs, which usually are not purchased in large quantities, can be more expensive, Reilly said.

Texas Tech staff members have been successful in avoiding bad outcomes by maintaining regular communication with other physicians in the area, Nahleh said.

“We share and borrow drugs,” Nahleh said. And “we are not preparing ahead of time so we don’t waste the drugs.”

Nahleh also credits the University Medical Center pharmacy.

“They should be praised with their good communication as to whether drugs will be back-ordered or in short supply,” Nahleh said. “If shortages hit you without any time to prepare, that would be the worst, worst situation.”

Notification from manufacturers has been a problem, Reilly said.

“A lot of times, we don’t find out about these shortages until we order the product,” he said. “That’s just not acceptable.”

Drug manufacturers are not legally required to report problems that could lead to shortages. Companies that are sole-source providers of drugs considered “medically necessary” — when no substitutes exist and they are part of life-saving therapies — must report to the FDA six months before they discontinue such a drug. However, there is no legal penalty for failure to comply.

The bill sponsored by Klobuchar and Robert Casey, D-Pa., would change that.

In most cases, the manufacturer would be required to notify the Secretary of Health and Human Services at least six months prior to the discontinuance or planned interruption of any pharmaceutical drug. It requires the secretary to establish fines for noncompliance.

“Physicians, pharmacists and patients are currently among the last to know when an essential drug will no longer be available. That’s not right,” Klobuchar said in an email. “This common-sense solution will help set up an early-warning system so pharmacists and physicians can prepare in advance and ensure that patients continue to receive the best care possible.”

A letter from the hospital association and other professional medical associations supporting the bill says it would give the FDA “tools to better manage — and hopefully prevent — shortages of life-saving medications.” It would make it easier for the FDA to monitor drugs that might soon be in short supply and to work with drug manufacturers to “establish contingency plans for manufacturing interruptions.”

Klobuchar’s bill was introduced in February. On Friday, it still was sitting in a Senate committee. If it passes, then it would be a first step, experts say.

One industry association has concerns that the bill would create “unintended consequences.”

“These concerns range from the potential release or sharing of proprietary information to competitors to the six-month notification requirement,” says the Generic Pharmaceutical Association in a recent press release.

The association recommended some solutions, including an expediting of approval for raw material suppliers that can step in when needed, removing regulatory barriers and expediting approval of changes to manufacturing lines and construction of new facilities, creating financial incentives such as tax credits, building government stockpiles of pharmaceutical ingredients and raw materials, and improving communication between the FDA’s enforcement arm and its drug shortage staff.

Reilly suggested that when a company owns a patent but is not producing the drug, other companies should be allowed to step in. Nahleh said measures could include “extending the expiration dates of drugs if appropriate and safe” and “expediting the approval of (new) drugs.”

“I believe one should focus on treating their patients and not scrambling to find the right drug,” Nahleh said.

REPEATED attempts to maintain peace at the Christmas Island Immigration Detention Centre are failing because many of the men held there are seriously mentally ill and others are frustrated that they can neither get a visa nor be freed, according to emails from asylum-seekers being held there.

Late on Tuesday night, the Australian Federal Police fired tear gas and bean bag bullets inside the Christmas Island centre.

The AFP yesterday revealed its officers had fired rubber bullets and teargas at Christmas Island detainees on five occasions this year.
Mexico pharmacy
The first three occasions were during a week of rioting and mass escapes that culminated in devastating fires, charges against 18 asylum-seekers and three complaints that the AFP had used inappropriate force.

Riot police were called back to the centre on June 10 and again fired tear gas and beanbag bullets, an AFP spokesman said.

In the latest unrest, which came after days of rooftop protests, about 50 men escaped their compounds and marched through the centre setting bins on fire.

Non-compliance and self-harm incidents have escalated. The visits room is now a “watch” area for detainees who have tried to harm or kill themselves.

Detainee Hotak Sahardost, who arrived by boat 14 months ago, said mental illness was rife there. “Unfortunately, many clients (detainees) after stay long time at here get many, many mentality health (problems) . . .

If I died in this detention, I am sure DIAC (the Department of Immigration and Citizenship) make for me some document tell(ing) anyone that I am crazy.”

The Australian has been told one detainee charged over the March riots was flown to a mainland mental hospital last month. He spent several days in psychiatric care at Graylands Hospital in Perth.

The Immigration Department’s security contractor Serco is trying to halt unrest on the island by converting the centre’s seldom used isolation cells – called Red Block – into a full-time behaviour management unit.

Detainees hate Red Block and resist going – one smashed a TV earlier this week after being told that is where he would be moved, The Australian has been told.

Mr Faridi said the situation was unbearable for stateless detainees like him who had been rejected.

“I accept the negative answer and I went for a request to go back to Iran, but the agent of immigration told me, ‘We cannot do that and send you to Iran because you are stateless and have not any document to able send you to Iran’,” he said. “I want to be free.”

Time to tee it up for mental health

Russ Courtnall is no stranger to pressure, having played in the National Hockey League.

But his life has become a whirlwind of activity recently in the countdown to the third Courtnall Celebrity Classic fundraiser for mental health. The amount of time Russ and his brothers Geoff and Bruce have spent on the phone organizing the event is a sign the fundraiser is near and dear to their hearts.

“It’s because it’s so personal with us, because of what happened to us,” Russ said from his home in L.A. “It’s not just a golf tournament and it’s just not a dinner, it’s more than that. With our dad committing suicide (in 1978), and being so young – I was 13 – unfortunately for us, it’s a big part of our lives, losing our father.”

Previous Classics in 2003 and 2004 combined to raise $2 million to establish the Royal Jubilee Hospital’s Archie Courtnall Centre – named for their father – where people suffering mental-health issues can receive emergency psychiatric care. Since it opened, 20,000 people have been cared for.

“I feel so good about it,” Russ said. “And some (who have received care there) are my friends, and some involved in the first two (fundraisers) have had family members go through it.”

This time around, Russ and Geoff, both former NHLers, and Bruce are looking to contribute to the Victoria Hospital Foundation, which has a goal of raising $4 million to pay for mental-health-care equipment and programs at the new RJH Patient Care Centre. It’s part of the foundation’s larger campaign to generate $25 million in support of the new centre.

Thanks to the brothers’ passion and round-the-clock dedication, around 2,000 people will be in attendance at several events this week, including a gala dinner Friday night (July 22) and a golf tournament Saturday.

Among the dozens of celebrities scheduled to attend include current NHLers Ryan O’Byrne of Victoria (Colorado Avalanche), Central Saanich’s Jamie Benn (Dallas Stars), Vancouver Canucks centre Manny Malhotra, L.A. Kings defenceman Willie Mitchell, and Ron MacLean, co-host of CBC’s Hockey Night in Canada.

Actors coming include Candace Cameron Bure from Full House and Make It Or Break It, X-Men: First Class actor Matthew Craven, Bold and the Beautiful TV star Jennifer Finnigan, Gena Lee Nolin from Baywatch and The Price is Right, and film actor Deborah Kara Unger from Silent Hill, Thirteen and Crash.

It’s too soon to tell if and when the brothers will hold another Courtnall Celebrity Classic. But they recognize how great the need is for mental health care, which fuels them to continue their efforts. “You help people and it’s so rewarding,” said Russ. “It’s great.”

Mental-health problems require more than Band-Aid approach

I
magine you’re at the office and your co-worker gets a paper cut, a really nasty one. How long until he or she gets a bandage out of a first-aid kit and stops the bleeding? Not too long. Now image you’re at the office and your co-worker is becoming more and more depressed. How long until he or she receives first aid?
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One in four people in the United States is affected by mental illness in any given year. Whether it is us, our family members, neighbors or co-workers, mental illness is prevalent. I’d even go so far to say that mental illness is nearly as common as a paper cut. Most of us will have the experience.

So how long do you think it takes people to get initial help for mental illness? Statistics show the average time between the onset of symptoms and engagement in treatment is 10 years. Compare that to the time it takes to treat the paper cut. It takes about a minute or two to find a small adhesive bandage and about another minute (depending on skill level) to apply the bandage.

So what’s with the 10 years? I think that with the paper cut, most of us are familiar enough with first aid to effectively expedite the process for ourselves or someone who needs help. The process is pretty easy to remember: apply sticky-side down, and you’re done. Historically, applying first aid for mental illness has been a far less common skill set.

The good news is that we’ve recently made huge gains in understanding how to assist people experiencing symptoms of mental illness. Perhaps, the most effective of these has been the emergence of Mental Health First Aid in the United States.

MHFA training provides instruction about skills to provide initial help to people experiencing mental-health problems such as depression, anxiety disorders, psychosis and substance-use disorders. The training is appropriate for community members; you do not need to be a trained behavioral-health professional to apply MHFA.

During the last two years, we’ve trained hundreds of people in the Four Corners including teachers, police officers, government officials, nonprofit employees, faith-based professionals, firefighters and folks who just wanted to learn these skills. As a certified MHFA trainer, I believe MHFA is shortening the 10-year average down to a few hours and is improving the likelihood of recovery for the people in our lives.

We’re in the process of planning our MHFA training schedule for the fall and winter, so please contact me if you’re interested in signing up for or hosting MHFA training for your organization or business.

Now here is a point to contemplate and defies logic. How could you possibly cause something that you do not desire or wish for? It’s a bit like stepping out onto a busy road without looking because you do not want to get run over by a car, bus, or truck.

The important issue is that ever since you experienced your first panic attack you most likely did not want to experience another one. In fact, you most likely feared having another attack and going through the embarrassment caused again. An interesting point is that fear is the basis of anxiety attacks, more precisely it is the fear of fear that perpetuates these attacks. The more fearful you have of having an attack the more fearful you become. It becomes a never-ending cycle.

This explains why you may have had a difficult time trying to put an end to the thought processes that occur when you are having a panic attack. The anxiety you are experiencing is triggering more anxiety, making you more anxious. You begin to start fighting the anxiety because you fear having another attack. You start to worry about the sensations you are experiencing which makes the anxiety worse and you feel like you are losing control.

As stated earlier there is no logical sense to panic attacks. On an intellectual level you realise that you are not in any danger and that you are over-reacting. However you cannot stop the escalating process from happening. You may find that you cannot talk yourself into regaining control. Sometimes just knowing what is happening to you and not being able to stop it makes you feel worse. The big question is why does this keep happening?

The secret to putting an end to panic attacks is to stop fighting the attack and act in reverse by welcoming the attack. This may seem to be paradoxical however surprisingly this method works! The question is, how can you be afraid of something that you welcome into your life? Panic attacks are merely a constellation of unwanted symptoms that will not cause you to die. At their worst they may cause you embarrassment and stop you from doing things that you want to do or enjoy. So lets say “bring it on, I’ve been through this before and I just want it all to stop after thirty seconds or so “.

Most legal scholars expect one of the suits to reach the U.S. Supreme Court, but not until its 2011-12 term that begins in October. Individuals, advocacy groups and hospitals have also sued.

The following are details of the current state of legal challenges to the law:

LAWSUITS MOST LIKELY TO REACH THE SUPREME COURT

* The Supreme Court on Monday refused to speed up a definitive ruling on the law in a suit brought by the state of Virginia, saying the state’s challenge must go through the typical appeals process. A U.S. appeals court in Richmond will hear oral arguments on May 10 challenging the recent ruling by U.S. District Judge Henry Hudson that the federal government could not compel a person to buy health insurance. In a twist, both the federal government and the state of Virginia appealed Hudson’s decision. Virginia says the judge erred by not throwing out the entire law. Hudson said the penalty charged for not having health insurance is not a tax, shooting down the federal government’s argument that it is based on its power to levy taxes.

* In a lawsuit filed by more than half the states and led by Florida, Judge Roger Vinson said the requirement that individuals buy health insurance is unconstitutional. A U.S. appeals court will hear arguments in early June in Atlanta. While Vinson said the entire health care law “must be declared void” because the requirement is inextricably linked to other parts of law, he put his decision on hold pending appeal.

OTHER RULINGS

* Another appeal, in a lawsuit filed by Liberty University, the college founded by conservative evangelical leader Jerry Falwell, will also be heard by the Virginia court on May 10. In November, a federal judge ruled the individual mandate and a requirement some employers buy coverage for employees was legal under the Commerce Clause. The judge also said the law did not illegally permit federal funding for abortion.

* In June, a U.S. appeals court in Cincinnati will hear an appeal in one of the first suits, filed by Michigan’s Thomas More Law Center. Last October, a federal judge partly dismissed the suit, ruling Congress had the authority to enact the law under the Commerce Clause of the Constitution.

* In April, the U.S. District Court in New Jersey decided two individuals who said they represented “we the people” and the “citizens of the state of New Jersey,” did not have any standing to sue, primarily because they could not establish they had been harmed by the law. The suit had said the law is illegal because it originated in the Senate, which cannot create revenue-raising measures on its own, and is unconstitutional because Obama is ineligible to hold the office of president. The court had already dismissed on Dec. 9 a lawsuit filed by a cardiologist, a patient and a physicians’ advocacy organization that had alleged the law violates the U.S. Constitution’s Commerce Clause and the Fifth Amendment.

* A California federal court dismissed a lawsuit, now before the the Ninth Circuit Appeals Court, that said the healthcare law violates individual rights, increases taxes and violates physician-patient privileges, along with violating the Commerce Clause.

* In November, U.S. District Court Judge David Dowd partially denied and partially granted a motion to dismiss a lawsuit filed by the U.S. Citizen’s Association in Ohio. While he dismissed arguments that the law violates freedom of association, due process and privacy protections, Dowd is considering arguments that the law exceeds federal authority granted by the Commerce Clause.

* At least 24 lawsuits have been filed in federal courts by states and private parties. One suit, Shreeve vs. Obama, was filed by a group of approximately 25,000 individuals and entities.

WHAT IS AT ISSUE?

* States like Virginia have passed, or are considering, legislation declaring the healthcare law cannot be enforced in their states. State legislators in Maine, Montana, Nebraska, Oregon, Texas and Wyoming have introduced bills that establish penalties, including fines and jail time, for any agent seeking to enforce the healthcare law within their states’ borders. North Dakota’s legislature passed a “nullification” bill in April authorizing it to enact any measure necessary to prevent enforcement of the law.

* The states’ main concern is that the law permits the federal government to force people to buy things, in this case requiring that all Americans purchase health insurance or pay a penalty under the “individual mandate.” The federal government counters that everyone will inevitably pay for healthcare, whether through insurance or during an emergency, and that without the individual mandate, premiums will rise.

* If the courts decide the individual mandate is unconstitutional, it is unclear if the mandate can be cut away from the law while leaving the other requirements intact. The states say that without the individual mandate the law is rendered toothless.

* Parts of the U.S. Constitution that have come into play are the Commerce Clause, which regulates commerce among states, the Supremacy Clause, which makes federal power supreme to states’ power, and the 10th Amendment, which leaves to states all powers not explicitly granted to the federal government.

* Some of the suits also focus on whether abortions are funded with taxpayer dollars under the law.

* When Obama lobbied for the bill, he said there would not be a new tax associated with the individual mandate requiring coverage. The penalty for not having health insurance, though, is collected through tax filings and the federal government argues the fine is indeed a tax it is empowered to levy. States say the U.S. government does not have the authority to charge the fine and point to the discrepancy between Obama’s statements and the U.S. government’s arguments.

Vermont Senate advances health care bill

The state Senate gave preliminary approval Monday to health care legislation that is a key part of Gov. Peter Shumlin’s agenda.

The bill, a version of which already has been passed by the House, would put Vermont on a path toward what it calls a “universal and unified health system” and what the Democratic governor calls single-payer health care, with the objective of ensuring health insurance coverage for every resident.

The Senate legislation won initial approval on a 21-8 vote and is due for final action Tuesday. It calls for setting up a health care marketplace, called an exchange, in keeping with federal health care legislation. It also sets up a board that would review and approve designs for a publicly financed program available to all residents.

Differences between the House and Senate versions of the legislation would be worked out in a conference committee, and then the bill would go to the governor for his signature.

Sen. Claire Ayer, D-Addison and chairwoman of the Senate Health and Welfare Committee, began the Senate debate by reading a comment from a resident upset with the rising cost of health care. Someone identified only as Aunt Serena wrote to The Burlington Free Press about the difficulties of paying medical bills.

“The patient not only has to be sick and is full of aches and pains and other hardships … (but also) has to scrabble to pay his taxes and his grocery and feed bills,” Ayer read.

Liberals Try to Rekindle Town Hall Fury That Inflamed Health Care Debate

Democrats still scarred over the town hall fury that inflamed the health care debate two summers ago and came to symbolize the unpopularity of that legislation are hoping Republicans suffer a similar fate over their deficit-reduction plan that would revamp social safety-net programs.

Democratic lawmakers and their liberal supporters are trying to ignite a storm of protest at town hall meetings being held by Republicans during the current congressional recess that they hope will give them momentum going into the 2012 presidential election season.

The GOP-led House this month approved Rep. Paul Ryan’s plan to cut $6.2 trillion from federal spending over 10 years and balance the budget by 2030 in part by making the elderly pay more for their Medicare. It would also cut the top income-tax rate for both individuals and corporations from 35 percent to 25 percent.

The plan has no shot of becoming law so long as Democrats control the Senate and the White House, which has released a plan that it says would cut $4 trillion over 12 years and would raise taxes on the wealthy. But liberals still want to punish Republicans who voted for it in hopes that it will help their party recapture the House and hold onto power in the Senate.

MoveOn last week reportedly urged its members to turn out at town halls and ask Republicans about plans to cut Medicare and Medicaid.

Rep. Lou Barletta of Pennsylvania faced outbursts at his town hall meeting that led police to remove a constituent. Others, including Rep. Charlie Bass of New Hampshire, Patrick Meehan of Pennsylvania, Robert Dold of Illinois, and Paul Gosar of Arizona, were grilled over the budget plan that would cut nearly $6 trillion from the deficit, in part by making the elderly pay more for their Medicare.

Ryan himself was booed lustily last week at his town hall meeting when he expressed support for cutting taxes for the wealthiest Americans.

Liberals have seized on that moment, arguing that residents in his own district don’t support the plan.

Ryan is holding more town hall meetings this week.

So far, the back-and-forth at GOP town halls have not risen to the level of the Democratic ones two years ago when there were near riots that ended in arrests and protests that fueled the Tea Party movement.

But liberal groups aren’t deterred.

Americans United for Change, a D.C.-based liberal group, has unleashed robo-calls in 23 Republican-held districts. The group has also targeted four lawmakers in particular with TV ads: Ryan and Reps. Sean Duffy of Wisconsin; Chip Cravaack of Minnesota and Steve King of Iowa.

In a statement, Tom McMahon, the group’s executive director, asked, “What are Republicans in Congress thinking, demanding that our most vulnerable citizens make more sacrifices but millionaires and big corporations to make less?”

As part of its effort to hold 25 House Republicans’ feet to the fire, the DCCC released an ad showing the elderly stripping at a house party, selling lemonade and struggling to mow lawns to pay for their health care under the Ryan plan.

“This is a defining moment for House Republicans: they chose to end Medicare rather than end taxpayer giveaways for Big Oil or tax breaks for the ultra rich,” DCCC Chairman Steve Israel said in a statement.

Sen. Barbara Mikulski, D-Md., sent out a fundraising email Tuesday for the Democratic Senatorial Campaign Committee, which is seeking to raise $145,590 by the end of the week, asking, “Is nothing sacred to these people?”

“First, Republicans spent months attacking women and families. Now they’re going after seniors,” she said. “There’s no end to what they’re willing to destroy to achieve their extremist vision.”

Claims by Democrats that the Republican plan would end social safety-net programs have been dismissed by fact-checking groups as outright lies.

But Republicans aren’t taking the attacks lying down.

“The Democrats tried to cover it up when they robbed $500 billion from Medicare to pay for their government takeover of health care, and now they’re using false scare tactics to again cover up the real Democrat plan to put a bureaucrat in-between seniors and their doctor,” Joanna Burgos, a spokesman for the National Republican Congressional Committee, said in a statement to FoxNews.com.

“The reality is that the Republican budget blueprint saves Medicare for future generations with no disruption for those in and near retirement, while the Democrats’ plan cuts Medicare benefits and raise taxes on job creators and every person who receives a paycheck.”

Memoir Highlights Long-Term Health Care Challenges

“A Bittersweet Season: Caring for Our Aging Parents — and Ourselves” (Knopf), by Jane Gross: Decades after screen star Bette Davis famously declared that “growing old is not for sissies,” Estelle Gross expanded on the woes of the ailing aged with her lament that people live too long and die too slowly.

On the day after the Sept. 11 attacks, after helping cover that story for The New York Times, an exhausted Jane Gross was finally able to drop by the nursing home a few miles north of ground zero where her mother had just moved to what would be her final residence. In a furious maternal vent, she greeted her daughter by saying, “I wish those planes had hit this building.”

Gross was a feisty octogenarian with a grab bag of chronic conditions that for nearly three years forced her to rely on others to carry out the simplest of daily activities. On the other hand, her cognitive abilities remained sharp until the end, a contrast to many others in her nursing home who endured the ravages of Alzheimer’s disease and other types of dementia.

Gross’ ordeal, and that of her daughter as principal caregiver, is one that is becoming more widespread as baby boomers are compelled to reverse the roles of their childhood and take on the challenging task of becoming their parents’ parents.

In her book, “A Bittersweet Season: Caring for Our Aging Parents —and Ourselves,” Gross, who went on to launch a blog called The New Old Age, recounts her own experiences in shepherding her mother through the intricacies and indignities of long-term care.

The narrative begins in 2000 with Estelle Gross’ move from Florida to New York, a “reverse migration” that is becoming more common for parents who need chronic care. It ends in 2003, when she dies at 88 in a nursing home after a decline that left her paralyzed, incontinent, unable to speak and unable to eat on her own.

An incisive reporter with a fine eye for detail, Gross laces her account of her mother’s decline and its impact on her own life with suggestions and warnings for other caregivers who find themselves in similar situations: Avoid the chaos of hospital emergency rooms, assume that costs associated with long-term care are not reimbursable by Medicare, find a family doctor, internist or — best of all — a geriatrician to manage the inevitable cascade of medical problems.

Gross recounts a succession of middle-of-the-night phone calls, emergency summonses from the workplace, financial costs that swiftly escalate and the need to play social engineer to ensure that nursing home staff aren’t slacking off when the need arises to change diapers or prevent bed sores.

“Once a parent has passed eighty-five, easy and affordable passings are few and far between. Believing you’re going to get one is magical thinking,” she writes.

The book is written from the perspective of the caregiver — more often a daughter than a son — whose relationship with the parent can be fraught with decades of resentment and other family baggage. In the author’s case, however, the ordeal brought her closer to her mother.

The path isn’t smooth, but rather an all-consuming and emotional roller coaster ride that Gross describes as “living in a soup of fear, guilt, heartbreak, resentment, loneliness, and exhaustion from bearing the weight of so much responsibility.”

While Gross’ memoir outlines the end-of-life decisions that often confront health care providers, clergy and ethicists, her mother’s ability to think rationally until the end gave her the control that others must often surrender. Instead, she exits on her own terms, without sentiment or self-pity.

“A Bittersweet Season” is sure to become required reading for anyone with an elderly parent who depends on long-term care. It’s also a worthwhile read for anyone who is interested in America’s health care system as it braces for the demands posed by demographic changes that include a sharp rise in the group now termed the “old old.”

Of course, the time to read the book is before the crises begin to mount, to be better prepared to make wise decisions and deal with whatever arises.

Awhile back the Washington Post ran an excellent article by Maia Szalavitz entited, “So, What Made Me an Addict? Experts Debate Whether Disease or Defect Is to Blame.”

This question is so crucial to how we treat persons suffering from both addiction and mental disorders, and especially how we deal with those with dual-diagnoses.

Just after I was discharged from Johns Hopkins Hospital, a friend of mine strongly encouraged me to go away to a halfway house of sorts for three or more months … where they treat addicts primarily, and some persons battling mental illness … in order to allow time to heal.

I ran it by my doctor. Did she think three months of AA meetings and yoga and group therapy would pull me out of my depression?

Her response was interesting, and one I remember in treating both my bipolar disorder and addiction:

“I don’t know of any facility other than a hospital that is equipped to treat a mental illness like yours. Being removed from your environment for three months or longer is very helpful for a person struggling with an addiction because it is primarily a behavioral disorder. They need to create new habits (healthy ones), and break all kinds of self-destructive patterns.

“But being away from your family, I’m gathering, would only make you feel more isolated. And it won’t be able to make your medication work any more quickly or be able to find the right combination faster. You are already doing whatever you can do to get well. In my opinion, it’s just a matter of finding the right drug combo until you’re stable enough to do even more cognitive work to recover completely.”

Here are some excerpts from the article:

Many people think they know what addiction is, but despite non-experts’ willingness to opine on its treatment and whether Britney or Lindsay’s rehab was tough enough, the term is still a battleground. Is addiction a disease? A moral weakness? A disorder caused by drug or alcohol use, or a compulsive behavior that can also occur in relation to sex, food and maybe even video games?

As a former cocaine and heroin addict, these questions have long fascinated me. I want to know why, in three years, I went from being an Ivy League student to a daily IV drug user who weighed 80 pounds. I want to know why I got hooked, when many of my fellow drug users did not.

A bill was introduced in Congress this spring to change the name of the National Institute on Drug Abuse (NIDA) to the National Institute on Diseases of Addiction, and the National Institute on Alcoholism and Alcohol Abuse (NIAAA) to the National Institute on Alcohol Disorders and Health. In a press release introducing the legislation, Sen. Joseph R. Biden Jr. (D-Del.) said, “By changing the way we talk about addiction, we change the way people think about addiction, both of which are critical steps in getting past the social stigma too often associated with the disease.”

But opinion polls find weak support for the concept of addiction as a disease, despite years of advocacy by such agencies as NIDA and NIAAA and by recovery groups. A 2002 Hart poll found that most people thought alcoholism was about half disease, half weakness; just 9 percent viewed it wholly as a disease.

So what does science have to say? Addiction research has advanced dramatically since my high school years in the early 1980s, when I began using marijuana and psychedelics, then cocaine, in the hope they would relieve my social isolation. My progression from psychedelics to coke was fed by a definition of addiction that still causes widespread misunderstanding. In 1982 — around when I first tried cocaine — Scientific American published an article claiming it was no more addictive than potato chips. This was based on the fact that cocaine users, unlike heroin users, do not become physically sick when they try to stop taking their drug.

Addiction, by this reasoning, is a purely physiological process, one that results from drug-induced chemical changes in the brain and body. Over time, with heroin and similar drugs, the article explained, the user develops tolerance (needs more of the drug to experience the same effect) and eventually becomes physically ill if he doesn’t have access to an adequate dose. Addiction, by this theory, is primarily an attempt to avoid physical withdrawal.

Celebrity disclosure of mental health disorders raises public awareness

Given his recent television interviews, viral video ranting and rooftop, machete-wielding tirades, it would not have raised any eyebrows whatsoever if it had been revealed that actor Charlie Sheen had checked himself into the hospital for treatment of a mood disorder. However, the recent disclosure by actress Catherine Zeta-Jones that she recently spent time in the hospital for treatment of Bipolar II Disorder did leave many surprised and some confused by her diagnosis.

In what used to be known as manic-depressive disorder, an individual with bipolar disorder can experience cycles of clinical depression alternating with episodes of manic or euphoric energy. During the manic phase of the illness, the person may be unable to sleep for days; display rapid or pressured speech, engage in behaviors that are risky, such as spending excessive amounts of money or becoming involved with people that are not well-known to them. They may exhibit grandiose thinking and in some cases lose touch with reality altogether. Someone with Bipolar II disorder will have depressive episodes but their mania will be less than full-blown. Or it may appear as irritability, rather than mania. According to some estimates, one in six people suffers from bipolar disorder.

The disclosure of a mental health problem by someone who is prominent, well-known or admired can have positive benefits. As anyone working in the field of mental health can attest, it is often stigma, shame or embarrassment that prevents an individual from seeking treatment. Back in the early 1980s, Academy Award winning actress Patty Duke revealed in her autobiography that after years of erratic behavior, mood swings, insomnia and self-medicating in an effort to manage her symptoms, she had finally been properly diagnosed with manic-depressive disorder, what we now call bipolar disorder. Not only did she seek treatment, she did something unprecedented at the time: she talked about her illness publicly, even before members of Congress did, in an effort to raise awareness and increase funding for mental health treatment.

Following her treatment for alcoholism at the Naval Facility in Long Beach, California, former First Lady Betty Ford went very public with her experience, opening her own treatment center, allowing both the well-known and the unknown to gain recovery from addiction.

Whether or not Catherine Zeta-Jones becomes an advocate for mental illness is unclear. But her disclosure has already dispelled at least one stereotype: you cannot always tell if somebody is suffering from mental illness merely by looking at them. Her admission may prompt someone who suspects something might be wrong to take the next, critical step — talking with someone. Trying to diagnose oneself is rarely productive, but talking with an experienced, well-trained professional can assist an individual in identifying whether or not they have a mental illness. While bi-polar disorder has tended to be overdiagnosed in recent years, careful assessment of symptoms can yield an accurate diagnosis. Psychotherapy and medication are usually an effective combination for managing the symptoms.

That Catherine Zeta-Jones was able to release the information herself, rather than having a tabloid “out” her, is indeed a victory. Her honesty, which has allowed an open discussion about a complex mental health issue, is a victory for everyone.